The data, which cover the period 2005-2008, indicate an overall MA-patient readmission rate of 14.5%.  This figure was compared against a published measurement of FFS patients (collected in 2004), which found a 19.6% readmission rate for patients in those plans.

After adjusting the numbers according to patient risk—the severity of their conditions—it’s calculated that the MA group had a 13% to 20% lower hospital readmission rate than the FFS group.

The reasons for the difference are not known. The researchers float a number of speculations, starting with the possibility that the risks of readmission were miscalculated because their analysis is based on diagnosis-related coding from patient claims forms. It’s conceivable that the forms may have missed some important factors affecting risk—such as health behavior and social support.  Or, perhaps, patients in MA plans are steered to high-performing hospitals, which would affect readmission rates.  Or, perhaps MA patients get better transitional care. (Full disclosure: VNSNY CHOICE Health Plans include a Medicare Advantage plan.)

Whatever the reasons, the MA numbers obtained from the analysis represent a benchmark, and, for sure, will be used by Medicare as a goal for the FFS plans, whose estimated cost for unplanned readmissions in 2004 was more than $17 billion.

^Reference

^{Lemieux J, Sennett C, Wang R, Mulligan T, Bumbaugh J. Hospital readmission rates in Medicare Advantage plans. Am J Managed Car 2012;18:96-104.}

According to one calculation, for every $1,000 increase in home health agency staffing costs to take on the added load, hospitals have saved at least $1,500 and perhaps as much $2,300 from reduced hospital payrolls.  Put another way, in the year 2008, the reduction in hospital costs may have been 36% larger than the increase in home health agency staffing costs.

This new analysis, which comes from a researcher at Columbia University Graduate School of Business, is based on mathematical models drawn from U.S. census and the Healthcare Cost and Utilization Project.

Does shorter stay in the hospital affect clinical outcomes?  The researcher’s admittedly cursory examination of mortality and home care found no statistically significant correlation.

“This may indicate that the substitution of home health care for hospital care does not have a major impact on health outcomes, but further research on this issue is warranted,” he concludes.

^Reference

^{Lichtenberg FR. Is home health care a substitute for hospital care? Home Health Care Serv Q 2012;31:84-109.}

The study¹ , carried out at three Veterans Administration sites, with 43 patients and nine nurses, found that:

• Almost three-quarters of the patients were fuzzy about why they had telemonitoring equipment in their homes, saying that it was there because the doctor said they had to be monitored
• A third of patients said they didn’t consider themselves experienced with electronic equipment
• More than a quarter of patients said they didn’t know what nurses did with the collected info
• Patients showed little understanding that they were supposed to apply the feedback information to their daily self-care
• Nurses believed that  frequent and timely communication meant the patient was using the feedback to better their self-care, which was not necessarily the case

The degree to which patients misunderstood the purpose of telemonitoring is demonstrated by the fact that only 29% of patients (and 70% of the nurses) agreed with the statement “The patient, telehomecare nurse, and home helper have the same goals for home telemonitoring.”

Based on such findings from their study, the researchers emphasize that “explicit information from the [telehomecare nurses] to the patient that the telestation is a direct communication that contains valuable data to be used for self-care is routinely needed.”

In other words, 1) nothing should be taken for granted, and 2) patients must be made to understand that telemonitoring is a tool they must use in order to maximize their own well-being.

^Reference

^{Shea K, Chamoff B. Telehomecare communication and self-care in chronic conditions: moving toward a shared understanding.}

^{Worldviews Evid Based Nurs 2012; published before print,  March 12. doi: 10.1111/j.1741-6787.2012.00242}

^{1It was not a trial.}

HAE occurs from genetic deficiency, either inherited or as a mutation in the patient, of a substance that regulates the movement of fluid and nutrients through the blood vessels.

The push for home infusion of the intravenous substance, known as C1-esterase inhibitor, is occasioned by the need for speedy treatment.  Attacks of HAE, characterized by edema, including swelling of the face and throat, are not only painful but can result in asphyxiation and death.  Time lost in getting to a hospital for administration of the intravenous substance allows an attack to become more severe.

In some patients, whose condition is more severe, treatment is not withheld until an attack but given preventively, as replacement therapy.

In the German retrospective observational study, 20 children, ranging in age from 7 to 17, received the treatment at home, either on-demand because of an acute attack or as replacement therapy. All were patients who had previously been treated at the clinic.

In evaluating efficacy, the researchers report that while time to treatment (including travel) was 67.5 minutes for clinic therapy, at home it was only 15 minutes. And while patient s were hospitalized an average of 3.8 days a year while on clinic therapy, once they switched to at-home intravenous infusion the number of annual days in the hospital was an average of 0.11.

Looking at safety, the investigators report no side effects from at-home therapy.

Training for at-home treatment was reportedly rigorous, covering:

• Written instructions and hands-on instruction by specialty nurses
• Ability to reconstitute the lyophilized blood substance and fill the syringe using sterile technique
• Disinfection of the injection site
• Peripheral venous puncture technique
• Management of any side effects
• Keeping a diary of the date, body site, and severity of an attack
• Making sure there was always a reserve supply of drug in the home
• Recording the amount of drug administered, including product batch number
• If the site of the attack was the larynx, and the patient did not rapidly respond to treatment, the German equivalent of our 911 emergency number had to be called and the dispatcher specifically told that it was a case of potential suffocation due to an HAE attack.  Further , in order to save time at the hospital, patients were instructed to bring unused drug with them

The researchers are not overplaying their 20-patient study results.  While pointing out that their results are promising, they emphasize that only a large randomized trial can confirm their findings in pediatric patients, including the very young.  [As noted earlier, the drug was recently labeled for at-home use in adults and adolescents in the U.S.]

^Reference

^{Kreuz W, Rusicke E, Martinez-Saguer Im, Aygören-Pürsün E, Heller C, Klingebiel T. Home therapy with intravenous human C1-inhibitor in children and adolescents with hereditary angioedema. Transfusion 2012;52:100-107.}

The single-blind pilot trial enrolled 30 frail patients, all older than 65 years of age, who were split into two groups. The experimental group of 15 underwent an exercise program, focused on walking capacity and functional activities, at home. Under the supervision of a physical therapist, the group had two 30-minute sessions twice a week for three to six weeks, and were encouraged to train an additional four times a week on their own or with the help of friends or relatives.

Regimens were tailored to individual patient needs. All were given a pedometer to monitor walking activity.

Patients in the control group received usual care, which consisted of a single session with the physical therapist at the hospital three weeks before surgery. Both the experimental and control groups learned particulars about the surgery, about post-op walking with crutches, and post-up exercise.

The researchers were primarily focused on feasibility of intensive pre-op home training. A previous pilot trial of pre-op exercise carried out at the hospital had shown some post-op benefit, but patients expended so much energy traveling to the clinic that many were too tired to exercise. That’s why the researchers decided to try a home program, where patients could put all their energy into an expanded exercise routine.

At the conclusion of pre-op training there was a significant difference between the two groups in various measures of physical activity. At six weeks post-discharge, there were no statistically significant differences, but there were hints of clinically meaningful differences favoring the at-home group.

The large randomized trial now ongoing will have the power to display statistical differences between the two treatment regimens, and will also look at cost.

^Reference

^{Oosting E, Jans MP, Dronkers JJ, Naber RH, Dronkers-Landman CM, Appelman –de Vries SM, van Meeteren NL. Preoperative home-based physical therapy versus usual care to improve functional health of frail older patients scheduled for elective total hip arthroplasty: A pilot randomized controlled trial. Arch Phys Med Rehabil 2012; 93:610-616}

Participants’ balance was measured pre-program, at the conclusion of the 12-week training sessions, and nine months later. The team found that the 98 individuals in the experimental arm of the study had not only improved balance during the training, but maintained it at the nine-month follow-up.

Further, those in the training arm had fewer falls—though this did not reach statistical significance—than individuals in the study’s control arm.

The regimen, known as Stand Up!, consisted of 12 biweekly intensive group sessions given by a professional therapist, with a handout poster showing simple exercises that could done at home.

How can just three weeks of training confer benefits that last at least nine months? It’s fair to say that the participants were motivated to carry out the exercises at home and, in general, to stay active.

The researchers acknowledge that theirs is a small trial. Nevertheless, they call their results on improving physical balance important because they indicate “that it is possible for a group exercise program delivered in real-world settings to reach a key prerequisite to reduce falls.”

^Reference

^{Robitaille Y, Fournier M, Laforest S, Gauvin L, Filiatrault J, Corriveau H. Effect of a fall prevention program on balance maintenance using a quasi-experimental design in real-world settings. J Aging Health 2012;published ahead of print, March 15, 2012.}

The university-designed study is meant to be carried out by personnel at community-based organizations such as senior centers, and is being tested at one such center, which is screening attendees for depression.

The single-blind, randomized study has an enrollment of 208 patients who have shown symptoms of depression on two successive questionnaires. After a baseline interview at home, patients either enter the program immediately, or four months later (control group).

Over a four-month period, the immediate-group patients receive 10 home visits/phone support from a licensed senior center social worker who has been trained in the program, known as Beat the Blues, and who assesses needs, makes referrals, provides education on depression, teaches stress-reduction techniques, and helps identify patient goals and the means of reaching them.

The primary endpoint of the study is symptom severity at both four-month and eight-month follow-up.  Patients (both the immediate group and the controls) will also be evaluated for effect on quality-of-life. The researchers will, in addition, be looking at other factors that may affect outcome: gender, age, and whether the individual lives alone or with others.

Persons eligible for enrollment are African-American, 55 years old or older, English-speaking, without cognitive impairment, who meet the diagnostic criteria of the depression questionnaires.

As for site of treatment, the researchers point out that older adults overall prefer home-based over clinic-based treatment, and this may contribute to a successful therapy outcome, as well as being cost-effective.

Trial enrollment is closed, and the treatment program is ongoing.  However, a preliminary cost of the program is already available. The program—screening plus the home intervention—cost $146.16 per participant per month (in 2010 dollars), which, the investigators take pains to point out, is cheaper than  a one-month supply of brand-name antidepressants such as Paxil, Zoloft, or Cymbalta.

And although the program was specifically designed for African-Americans, it would be suitable for other minority groups as well, according to the investigators.

“If [the program] is efficacious and cost-effective, it will represent a promising new approach for depression detection and treatment for older African Americans, warranting replication and implementation in other senior centers and the aging network in the USA,” the researchers conclude.

^Reference

^{Gitlin LN, Fields Harris L, McCoy M, Chernett NL, Jutkowitz E, Pizzi LT.  A community-integrated home based depression intervention for older African-Americans: description of the Beat the Blues randomized trial and intervention costs. BMC Geriatr 2012, 12:4 published ahead of print, doi:10.1186/1471-2318-12}

It seems, for example, that patients learning their blood pressure is outside the normal range are more likely to worry, or ask more questions, if they receive the info face-to-face than through the telemonitoring equipment.

When receiving the information via equipment, patients seem more likely to passively accept the results.  Face-to-face, patients are more likely to discuss how the abnormal reading will affect their future health. This might mean greater motivation to change to a healthier lifestyle.

The authors of the study are not saying that telemonitoring is bad, only that those who design the monitoring programs have to keep in mind how patients will receive the info, and make sure it’s delivered in a way that motivates patients to change their behavior.

The study, which is only in its pilot phase, was conducted with five heart failure patients, recently discharged from the hospital, who were on the rolls of a home health care agency.

The patients were presented with scenarios in which they were asked how they would feel and what would they do if, in real life, they were told about various healthy and unhealthy behaviors they had engaged in, and various normal and abnormal results.  All the patients had telemonitoring equipment in their homes.

In the telemonitoring scenarios, patients given bad test results seemed to just accept them without appropriate worry about their implications.

The researchers theorize that when test results are delivered by a live professional, there is opportunity for discussion and questions about the implications down the line.

We all know that once technology exists, there’s no going backwards—it’s used. The researchers know this, as well.  What they say is: “It is important to be careful not to use technology to disengage chronically ill patients from taking responsibility for monitoring their own health status. Transition to healthy independence is a goal of home health care, and telemonitoring technology should be used in a manner that is supportive of that goal. A balance between providing professional oversight and motivating patient self-care is imperative if [the] home health nurse is to decrease hospital readmissions and prolong independent living.

^Reference

^{Shea K, Chamoff B. Patient reactions to vital sign measures: comparing home monitoring technology to face-to-face delivery. Home Health Care Manag Pract 2011;6:454-460.}

Only to be expected, you say? But would you expect that greater continuity of care is not simply a matter of patients ‘feeling better,’ but can affect the patients’ need for hospitalization and thus the monetary cost to the community?

This has now been demonstrated in two retrospective studies carried out by the Visiting Nurse Service of New York (VNSNY) using its own patient database.

In the first study, of almost 60,000 acute care patients seen exclusively by registered nurses, patients with greater continuity of care required fewer visits to the emergency room, were less likely to be hospitalized within 60 days of initiating VNSNY care, and showed greater improvement in their ability to carry out the activities of daily living.¹

Such results mean that that not only should home health agencies strive for greater consistency in assignment of personnel to patients, but such consistency should become a measure of an agency’s quality of care, the VNSNY research team believes.

The second study analyzed the responses of more than 35,000 patients receiving at least three physical therapy visits for a variety of complaints.

The items measured were hospitalization within 60 days of VNSNY enrollment, reduction in the number of activities of daily living being treated, and improvement in the severity of the activities being treated.²

Once again, there was a link between continuity of care and patient outcome. Patients with greater continuity were less likely to require hospitalization, and had greater likelihood of improvement in both the number and severity of limitations on their daily activities’ scores.

This is evidence that “breaks in provider continuity compromise the restorative effectiveness of physical therapy services,” the VNSNY team comments.

“Lack of continuity is likely to affect various interpersonal aspects of the relationship between a patient and a physical therapist, including communication, trust, and the ability of the physical therapist to reevaluate the patient between visits,” the researchers add.

Of course, continuity can never be entirely seamless—nurses and physical therapists, like everybody else, have holidays and take vacations. Nevertheless, the VNSNY researchers maintain, the importance of matching therapists and patients should become a high priority, and “senior and clinical managers should encourage an organizational culture that puts continuity ahead of convenience.”

^References

^{1. Russell D, Rosati RJ, Rosenfeld P, Marren J. Continuity in home health care: is consistency in nursing personnel associated with better patient outcomes? J Healthc Qual 2011;33:33-39.}

^{2. Russell D, Rosati RJ, Andreopoulos E. Continuity in the provider of home-based physical therapy services and its implications for outcomes of patients. Phys Ther 2012;92:227-235.}

The double-blind, randomized trial enrolled 60 post-partum-depressed women, 27 in the 12-week group , and 33 in the 2-week group (controls), who had validated postnatal depression and a baby less than 9 months of age.

The controls had a 12-week waiting period before treatment; the others began treatment immediately. The women were allowed to have whatever therapy was available from their family doctors, public health nurses, or other support in their communities. The researchers also referred all patients to community resources, and there were on-call nurses and mental health aides.

The patients were matched with women who had recovered from postnatal depression within the previous two years, were willing to make weekly home visits to the patients and be available by phone, and who were given what was believed to be appropriate training

When results were analyzed, there was a significant difference, favoring the control group, in maternal-infant interaction teaching. Symptoms of depression and perceived social support were also significantly different between the two patient groups, again favoring the controls.

How come? Running through the list, the researchers cannot exclude the possibility that the patients in the treatment group were actually more depressed than the controls. Or, the volunteer helpers may not have been adequately trained. Or maybe they found it hard to teach the patients. Or the babies were too old—an average of five months—and intervention should have begun sooner, not just in women who have been diagnosed, but those who were deemed at risk. Or just maybe the support should be delivered by professionals such as nurses and psychologists, either alone or in tandem with peer-group volunteers.

^Reference

^{Letourneau N, Stewart M, Dennis C-L, Hegadoren K, Duffett-Leger L, Watson B. Effect of home-based peer support on maternal-infant interactions among women with post-partum depression: A randomized controlled trial. Int J Ment Health Nurs 2011;5:345-357.}